HIV Criminalization

In May 2008, a homeless, HIV+ man was sentenced to 35 years in prison for assaulting a police officer with a "deadly weapon, his saliva! Willie Campbell, who was clearly intoxicated at the time, has been HIV+ since 1994 and has a history of aggressive behavior with public servants, will have to serve at least 17.5 years to be eligible for parole. The police officers were not infected. According to the Centers for Disease Control (CDC), although there have been a few rare cases of transmission through severe bites, “contact with saliva, tears or sweat has never been shown to result in transmission of H.I.V.”

Thirty four states, 2 U.S. territories and numerous other countries (including Russia, Finland, Australia, England and 20 countries in Sub Saharan Africa) have HIV specific criminal statutes. Other U.S. States and some other countries have used non-HIV specific charges such as assault with a deadly weapon and attempted murder. Many of these laws and prosecutions do not differentiate between whether an HIV+ person used a condom or even whether the virus was transmitted. All of this begs the question: Should we even be on this slippery slope?

Being HIV+ is not a crime. With the new developments in treatment, it is no longer a death sentence. Moreover, recent studies have demonstrated that one of the most effective methods of prevention is aggressively treating individuals with HIV, thereby lowering their viral load so that they may be less infectious. Studies have also shown that people who know there status tend to behave more responsibly. Unfortunately, the CDC estimates that as many as 1 in 5 people who are HIV+ are unaware of their status. Therefore it is crucial that people know their HIV status.

I understand the fear and demagogory that has dogged the HIV epidemic. And, I am certainly not making the case for irresponsibility when it comes to having sex. I get it! But we have made significant gains in this country, not just in treatment, but in making HIV testing a routine part of medical care. The last thing that we need is to arm prosecuters with powerful laws to 'punish the victim,' eg... to lock away hundreds, if not thousands of HIV+ people to protect us from them. And what responsibility does the 'partner' have in all of this. Does a person have to be told that their potential partner is HIV+, before they will use a condom?

Unfortunately, this issue is much more complex that the time and space that I will currently give to it. Perhaps the greatest concern is that these laws, which were no doubt designed to prevent infection, will more likely have the opposite effect of scaring people away from getting tested. After all, what is to stop a scorned ex-lover from pressing charges, stating that they WERE NOT TOLD of their partner's HIV status. Haven't we learned that punitive action is not always the answer. In other words, in our efforts to prevent the spread of HIV, the shield is mightier than the sword.

AIDS Denialism

Recently, someone named Curtis Cost wrote an article assailing the importance and validity of African Americans knowing their HIV status. Since the first widely reported cases in 1981, HIV has been mired in controversies, ranging from its origin to the possible existence of a cure. Sadly, over thirty years later, we continue to have many of the same conversations. What should NOT be in doubt any longer is that HIV disease is having a devastating impact on the African American community. Although African Americans represented only 14% of the US population in 2009, we accounted for 44% of all new HIV infections in that year. Overall, African Americans account for a higher proportion of HIV infections at all stages of disease—from new infections to death, than any other racial of ethnic group. Moreover, as many as 21% of people living with HIV are unaware of their status and, consequently cause up to 70% of the new infections. So why then, would Mr. Cost write such an impassioned plea for African Americans to NOT get tested for HIV? In short, we refer to people like Mr. Cost as AIDS Denialists. AIDS Denialists represent individuals or groups who deny that the human immunodeficiency virus (HIV) is the cause of Acquired Immune Deficiency Syndrome (AIDS). While the link between HIV and AIDS has long been established in the scientific community, AIDS Denialists continue to dismiss HIV as a harmless passenger virus and assign the cause of AIDS to anything from malnutrition to the drugs used to treat it. Now, before you dismiss the Denialists as just foolish or uninformed, let me remind you about Thabo Mbeki, the former President of South Africa and once a poster child for AIDS Denialism. By some estimates, his alleged 'fiddling while Rome was burning' may have led to as many as 330,000 AIDS deaths as well as almost over 200,00 new HIV infections.

The greatest weapon against AIDS Denialists is knowledge, ours. AIDS Denialists prey on our own cynicism, ignorance and, yes, our denial. It always amazes me how willing we are to jump on the bandwagon of someone offering very little in the way of proof and disavow decades of scientific evidence. Healthy skepticism can be a good thing. However, use that cynicism to motivate yourselves to seek more information. In other words, do your own homework!

Can Certain Contraceptives Increase HIV risk?

I can imagine that those who try to remain current with new developments in contraception and HIV risk reduction may cringe at discovering that something else might place them at increased risk of HIV infection. This time, that something else may be a popular form of contraception, injectable hormones. Injectable hormones, such as the well-known Depo-Provera, are one of the easiest, most cost effective contraception alternatives because they are long lasting, easily administered and and gives women more control over the timing of their pregnancies. Unfortunately, they do not protect against HIV or other sexually transmitted infection. Now, a recent study published in Lancet on October 3, 2011, raises concern that their role in HIV infection might be even more problematic. Researchers from the University of Washington followed almost 4,000 couples for two years in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia. In each couple, either the man or the woman was already infected with HIV.

The study found that women using hormonal contraception became infected at a rate of almost twice as high compared with those not using that method. Transmission of HIV to men also occurred at a rate almost double from women using hormonal contraception than for those who did not. Two other major ones have also demonstrated increased risk of HIV through the use of injectable contraceptives.

It is not entirely clear why this may be happening. The Progestin in injectable contraceptives may have a physiological effect, such as immunologic changes in the vagina and cervix. Moreover, researchers found more HIV in the vaginal fluid of those using hormonal contraception than those who did not. This might help to explain why men might have increased risk of infection from hormonal contraceptive users.

While the results of this study may be quite sobering, especially to those who use injectible hormonal contraceptives, it is just as important that we remember that for most, HIV risk reduction still remains firmly within our control and underscores the importance of not just knowing one's own HIV status, but that of our partners.

Treatment is Prevention Part 1

Some of you may be aware that the annual HIV Prevention conference has been taking place in Atlanta this week. One of the unique aspects of HIV conferences is that they tend to bring together an eclectic mix of people: consumers, researchers, medical providers, non profits and other assorted advocates. As we, as a society, struggle with finding new and creative ways to reduce the transmission of HIV, it was only natural to consider the impact a medical model might have on this challenge. Perhaps one of the most exciting studies within the last several months demonstrates the benefit of immediate, aggressive HIV treatment in reducing transmission.

Historically, HIV prevention targeted those who were negative. Eventually, more emphasis was placed on "Prevention for Postives," which focused primarily on changing the potentially risky behavior of people who are HIV+. However the promising results of a study, known as HPTN 052,that evaluated whether the immediate use of HAART (Highly Active Anti-retroviral therapy) by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners (which would also potentially benefit the HIV-infected individual), demonstrates the increased role of medical treatmet in prevention. The results of the study were truly groundbreaking: there was a 96 percent reduction in risk of HIV transmission to the HIV-uninfected sexual partners.

The results of this study underscores previous efforts to test as many people as possible by making HIV a routine part of medical care as well as aggressive community mobilization by showing that if we can get HIV+ individuals into care and keep them there, it may reduce overall HIV incidence and save lives. Put another way, this study adds another needed weapon to our arsenal as we continue to make progress if our war against this formidable, entrenched enemy: HIV.

HIV at 30

For the two or three of you (lol) who follow my blog, you may have noticed that I haven't blogged in a while. A lot has happened to me over the last several months that I won't get into now. However, I have returned with a renewed sense of purpose and quite a lot to say.

Much has been written about the 30th anniversary of HIV. I plan to write throughout the year on this topic. It is long and complex area and I cannot begin to do it justice in one or two blogs. So hear I go......

My blog today will be more in the form of a rant. It comes on the heels of a recent radio show on which I appeared. During the show, I experienced a sense of déjà vu; that the conversation I was engaged in has happened before. After 30 years, I was answering many of the same questions, the same way:

* Why are the rates so high in the African Americans so high?
* Whay aren't the churches more involved?
* Why do so many African Americans have conspiracy theories?
* Isn't Magic Johnson cured?
* Why is the stigma so great?
* Isn't AIDS a gay disease occurred to me?

After 30 years, with so many ways to access the information, why hasn't it sunken in? Moreover, this 'HIV illiteracy' does not seemed to be impacted by SES (socio-economic status) I have had the same conversations with people ranging from 6th grade reading levels to doctorates.

Certainly the glass isn't completely empty. We have made strides. There is finally a National HIV strategy. Many cities have instituted robust social marketing and testing intitiatives. And, some faith-based institutions have become involved. But, as I have these daily conversations and watch the rates continue to rise, it still seems apparent that it just hasn't sunken in enough. Without our most important asset, knowledge, we still have a long way to go.

2010- a Year of Promise

For so many years, the news about efforts to combat HIV/AIDS has been, in a word, depressing. It seemed that with every positive development would come news of escalating infection rates, or that some promising vaccine or therapy was less promising than we had hoped. But 2010 will be remembered as one of the first years where there seems to be almost universal optimism that real progress is being made in this war.

Perhaps the most optimistic front has been in the area of science. During this year, we have been uplifted with promising results of studies raging from the possible efficacy of microbicides, to the potential of gene therapy. At the International AIDS Conference, one of the major themes throughout the event was that effective HIV treatment IS prevention i.e., that reducing viral load may be an effective tool in reducing infection rates. Moreover, for many years, the idea of a pill that could prevent HIV infection was almost universally derided. Yet with the recent announcement of the National Institutes for Health study of pre –exposure prophylaxis in MSM, we now may have another tool to reduce infection rates in individuals at greatest risk.

Not all of the positive news has just been in the field of science. Thanks to President Barack Obama, the United States has its first National HIV/AIDS Strategy with an extra 30 million dollars added for HIV prevention (and 25 million for the struggling ADAP program). Moreover, with the reopening of the National AIDS Policy Office, the approval of needle exchange, the elimination of the travel ban for people with HIV and most importantly, the passing of the Affordable Care Act, the United States has finally taken a broad, visible leadership role in fighting this epidemic.

So while there is undoubtedly good news, there also remain challenges. Less than half of the individuals needing HAART are receiving it. Moreover, the global recession has caused historic belt tightening throughout the world. In the United States, many states and cities are either reducing or considering reduction in HIV/AIDS services. Even staunch HIV advocates are reflecting on the monumental task (not to mention the expense) of keeping tens of millions of HIV+ individuals alive with HAART indefinitely, a lifetime cost that a Cornell University study estimated at $600,000 per person.

So where do we go from here? Perhaps the greatest optimism during 2010 has been the belief from many HIV researchers that a cure may be on the horizon. There are several very promising areas of “cure” research with promising results. However, in this case, the ‘devil is not in the details,’ but in the dollars. In order to find a cure, whether a functional one that allows people to maintain an undetectable viral load without medication or an eradication cure, it will take a lot more money then is being expensed now. For example, the cost of researching and developing a single drug has been estimated at 500 million to 2 billion dollars.

The hundred dollar question is: will we demonstrate the commitment, through the economic resources and the will to revamp the infrastructure to facilitate cure and vaccine research, or will we keep looking around and hoping for some lucky, miraculous (and cheap) breakthrough? A wise man once coined the phrase to me that the history of AIDS is still being written. Let’s make this next chapter, 2011, the year where WE gave the bully a bloody nose.

Disturbing New Information on MSM and HIV

One of the most frustrating aspects of working in HIV is addressing the many myths (as well as conspiracy theories) surrounding it-the most persistent of which is that AIDS is a "gay disease." Clearly this myth started early in the history of HIV in the U.S., yet has persisted despite clear evidence of how HIV is transmitted and the growing diversity of those whom become infected. Moreover, it has been convenient for many to affix the label of "gay" to anyone who has had sex with the same gender. However, a startling new report from the Centers for Disease Control (CDC) may add additional fuel to that myth. A CDC study conducted in 21 cities tested over 8,000 gay and bisexual men participating in the 2008 National HIV Behavioral Surveillance System.

The study found that almost one in five men having sex with men (MSM) was infected with HIV and that almost half of them did not know it. Black MSM were infected at a rate of 28%, as compared to 18% for Latino men and 16% for Caucasian MSM. Black MSM were even less likely to know their status than other races (59% were unaware) with young black MSM, a shocking 71% of which were unaware of their status. There was also a high co-morbidity with HIV status and socioeconomic variables-with HIV + status increasing as education and income decreased.

Studies such as these point to the glaring need for new creative strategies, not to mention social marketing approaches, to attract more and younger MSM to get tested. Moreover, despite all of the hoopla about '"men on the down low" as the culprit for rising infection rates with women, we cannot overlook the fact that many of the men in this study were bisexual and therefore, may have female partners. Previous studies have shown us that when someone knows their HIV status they are more likely to practice safer sex. Hopefully a renewed focus on HIV prevention targeting MSM may lead to a sorely need national dialogue revealing the diversity and complexity of the topic. Perhaps that discussion will help dispel the myth.